Amenorrhoea

Question 1

Primary amenorrhea

Answer 1

Failure of menstruation by the age of 16 years in the presence of normal secondary sex characteristics
OR
14 yrs in the absence of other evidence of puberty

Question 2

Secondary amenorrhea

Answer 2

Absent periods for at least 6 months in a woman who has previously had regular periods, or 12 months if she has previously had oligomenorrhoea

Question 3

Group 1 Amenorrhoea

Answer 3

Low oestrogen, low FSH, no hypothalamic-pituitary pathology

Hypogonadotrophic hypogonadism

Question 4

Group 2 Amenorrhoea

Answer 4

Normal oestrogen, normal FSH, normal prolactin

PCOS

Question 5

Group 3 Amenorrhoea

Answer 5

Low oestrogen, high FSH

Gonadal failure

Question 6

Tanner stage 1

Answer 6

Breast and pubic hair prepubertal

Question 7

Tanner stage 2

Answer 7

Breast buds seen

Few hairs at labia majora

Question 8

Tanner stage 3

Answer 8

Larger breast buds

Mainly central growth of pubic hair

Question 9

Tanner stage 4

Answer 9

Mound formed

Triangular shaped area of pubic hair

Question 10

Tanner stage 5

Answer 10

Fullly formed breasts

Adult shape pubic hair, spread to thighs

Question 11

Causes of Amenorrhoea (subdivisions)

Answer 11

Pregnancy
Haematocolpos 
Hypothalamic dysfunction (chronic illness, weight loss)
Hydrocephalus, empty sella syndrome, craniophayngioma
Prolactinoma
Thyroid disorders
Cushing syndrome
Consitutional delay
Genetic disorders (Turners)
Androgen secreting tumors
Premature ovarian failure
PCOS
Ashermans
Head injury
Sheehan’s syndrome
Chromosomal abnormalities (fragile x)

Question 12

Most common causes of primary amenorrhoea

Answer 12

Gonadal dysgensis (43%)
Mullerian agenesis (15%)
Constitutional (14%)
PCOS (7%)

Question 13

Hirsuitism virilisation

Answer 13

May be due to an androgen-secreting ovarian or adrenal tumor, or 5 alpha-reductase deficiency

Question 14

History points for primary amenorrhoea

Answer 14

Psychological dysfunction or emotional stress
Mother and sister gynae hx
Mother obs history with child
Fam hx (genetic disorders, diabetes, delayed puberty)
Pubertal development
Galactorrhoea
Hypothyroid symptoms
Weight loss or gain
Hirsuitism virilisation
Menopausal symptoms
Sexual activity
Headache or visual disturbance, Polaris, poldipsia
Anosmia
Chronic illness
RT or CT

Question 15

Secondary amenorrhoea hx

Answer 15

Irregular menstraul cycles
Hirsuitism
Acne
Malaise, fatigue, weight loss
Heterotopic ossification (following head injury)
Headaches
Galactorrhoea
PPH - ?sheehan’s
D&C ?asherman
Medications
Rapid virilisation
Hyperprolactinemia

Question 16

Conditions with a blind vaginal pouch

Answer 16

Mullerian agenesis
Transverse vaginal septum
Androgen insensitivity syndrome

Question 17

Testosterone >5

Answer 17

Androgen insensitivity
Androgen secreting tumors
Cushing syndrome
Late onset CAH

Test in both primary and secondary amenorrhoea

Question 18

Raised FSH/LH and secondary sexual characteristics

Answer 18

PCOS

Question 19

Primary amenorrhoea with normal FSH and secondary sexual characteristics

Answer 19

?obstructed outflow tract

Haematometra and haematocolpos

Question 20

High FSH and no secondary sex characteristics

Answer 20

17-alpha hydroxylase deficiency (with HTN)

If high LH, turner’s sndrome or male karyotype

Question 21

Low FSH and LH

Answer 21

Intracranial lesions and Craniopharyngioma if short stature

Normal height or normal FSH, weight loss, celiac diseae, type 1 DM, anorexia nervosa or exercise

Question 22

High FSH and secondary amenorrhoea

Answer 22

Premature ovarian failure if on 2 occasions >20

Question 23

Space occupying lesion of the hypothalamus pathophysiology

Answer 23

Tend to occur around the time of puberty
Cause amenorrhoea by disrupting the tonic inhibition of dopamine on prolactin release and/or compress and destroy hypothalamic and pituitary tissue

Question 24

Kallman’s syndrome

Answer 24

1:50000
Congenital absence of GnRH neurons whose cell bodies from the olfactory area to the arcuate nucleus of the hypothalamus
May be sporadic or inherited
AD or X-linked recessive
Associated with anosmia and colour-blindness

Question 25

Prolactin level 700-2500

Answer 25

Hypothyroidism/PCOS Check TSH, T4, FSH/LH, testosterone, SHBG

Question 26

Prolactin <3000

Answer 26

Non-functioning macroadenoma MRI or CT head (if >1500 x 2 occasions)

Question 27

Prolactin 1500-4000

Answer 27

Functioning microadenoma Image

Question 28

Symptoms of hyperprolacinaemia

Answer 28

Oestrogen deficiency Galactorrhoea (30%) Visual field defects (5%)

Question 29

Bromocriptine treatment for hyperprolactinaemia

Answer 29

1.25mg nocte for 5 nights Gradually uptitrate to 7.5mg daily in 2 or 3 divided doses over three weeks SE: nausea, vomiting, headache, postural hypotension, Raynauds, constipation, psychiatric hanged (aggression)

Question 30

Cabergoline for treatment of hyperprolactinameia

Answer 30

0.25-1mg twice weekly Up to 1mg daily Longer acting and better tolerated but still second line due to adverse psychiatric effects and not Licensed for pregnancy

Question 31

Quinagolide for treatment of hyperprolactinaemia

Answer 31

25-150mcg daily in divided doses Longer acting and better tolerated but still second line due to adverse psychiatric effects and not Licensed for pregnancy

Question 32

Prolactinomas and pregnancy

Answer 32

80% achieve pregnancy on dopamine agonist treatment No increase in miscarriage, ectopic or other complications of pregnancy Can BF Some develop signs of tumor growth in pregnancy, <2% for micro, 15% macro Bromocriptine ok in pregnancy

Question 33

Empty sella syndrome (cause, consequence and treatment)

Answer 33

Benign congenital absence or following surger or RT Extension of the subarachnoid space into the pituitary fossa flattens the pituitary separating it from the hypothalamus; usually get hyperprolactinaemia Bromocriptine

Question 34

Sheehan’s syndrome (cause consequence and treatment)

Answer 34

Acute infarction and necrosis of pituitary due to PPH and shock Hypopituitarism; failure of lactation and loss of pubic hair; deficiencies in GH, gonadotrophins, adrenocorticotrophin, Thyroid hormone To: pituitary hormone replacement and oestrogen and progesterone

Question 35

uterine causes of secondary amenorrhoea

Answer 35

Asherman syndrome | Cervical stenosis

Question 36

Ovarian causes of secondary amenorrhoea

Answer 36

``` PCOS POF (genetic, autoimmune, infective, RT/CT) ```

Question 37

Hypothalamic causes of secondary amenorrhoea (hypogonadotrophic hypogonadism)

Answer 37

``` Weight loss Exercise Chronic illness Psychological distress Idiopathic ```

Question 38

Pituitary causes of secondary amenorrhoea

Answer 38

Hyperprolactinaemia Hypopituitarism Sheehan syndrome

Question 39

Hypothalamic/pituitary damage (hypogonadism)

Answer 39

``` Tumour Cranial irradiation Head injury Sarcoidosis TB ```

Question 40

Systemic causes of secondary amenorrhoea

Answer 40

Chronic illness Weight loss Endocrine disorders (Thyroid disease, Cushing)